Chapter 22 Urinary System

A postpartum client with a difficult vaginal delivery 36 hours ago tells the nurse that she has not felt the need to void much since delivery. Which response by the nurse is the most appropriate? 1. "The inside of your bladder is most likely swollen, which makes you feel like you don't have to urinate." 2. "You must be overdoing it with your activity level so soon after delivery." 3. "I will need to catheterize you." 4. "Your uterus must not be enlarged any longer."

Correct Answer: 1 During childbirth, the bladder mucosa may become edematous, causing decreased sensation and potential overdistention of the bladder, which increases susceptibility to infection and other postpartum problems. An increase in activity level would not cause the client to have a lack of sensation to void. Immediate catheterization would not be necessary as long as the client is able to void in adequate amounts. A decrease in uterine size would not cause the client to have a decreased sensation for the need to void.

During the assessment of a client's urinary system, the nurse learns that the client has painful urination. Which term will the nurse use when documenting this finding in the client's medical record? 1. Dysuria. 2. Hematuria. 3. Oliguria. 4. Polyuria.

Correct Answer: 1 Painful urination is termed dysuria. Hematuria is blood in the urine; oliguria is decreased urine output; polyuria is increased urine output.

During the assessment of a client with multiple injuries, the nurse notices a large hematoma located at the left costovertebral angle. The nurse should suspect injury to which organ? 1. Kidney. 2. Ribs. 3. Intestines. 4. Bladder.

Correct Answer: 1 The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3, also termed the costovertebral angle.

The nurse is preparing an educational session on kidney health for a church group. Which would the nurse include as the leading causes of end-stage renal disease? Select all that apply. 1. Diabetes mellitus. 2. Alcoholism. 3. Hypertension. 4. Cardiovascular disease. 5. Obesity.

Correct Answer: 1, 3 Diabetes and hypertension increase the risk for end-stage renal disease. Alcoholism, cardiovascular disease, and obesity are not leading causes of end-stage renal disease.

The nurse is obtaining a medication history on a newly admitted client with renal dysfunction. Which medication classification would the nurse note as significant for this client? 1. Antihypertensives. 2. Analgesics. 3. Antihyperlipidemics. 4. Diuretics.

Correct Answer: 2 The prolonged use of analgesics, especially over-the-counter drugs like ibuprofen and acetaminophen, has been linked with renal disease.

The nurse is preparing to catheterize a client who has just voided. Which is the purpose of this catheterization? 1. To obtain a baseline urine output. 2. To support the diagnosis of kidney stones. 3. To evaluate the ability of the client to empty the bladder. 4. To evaluate renal function.

Correct Answer: 3 This procedure is a post-voiding residual urine test. This procedure would not indicate urine output baseline, kidney stones, or renal function.

A client experienced blood loss from surgery. What is the impact of this blood loss on the kidney's functioning? 1. Altered filtering ability of the kidneys. 2. No impact on kidney function. 3. Absorption of calcium and phosphate decreased. 4. Stimulation of the kidneys to produce erythropoietin.

Correct Answer: 4 The kidneys would produce the hormone erythropoietin in response to the blood lost during surgery. Erythropoietin then stimulates the bone marrow to produce red blood cells. Blood loss would not cause altered filtering ability, or decreased absorption of calcium and phosphate from the kidneys.

The nurse is measuring the urinary output for a client and notes 450 ml of urine. Which conclusion by the nurse is the most appropriate? 1. Decreased from normal. 2. Concentrated from what is normal. 3. Increased from normal. 4. Normal amount.

Correct Answer: 4 The size of the bladder varies with the amount of urine it contains. In healthy adults, the bladder holds about 300 to 500 ml of urine; therefore, 450 ml would be considered a normal amount of urine. Concentration of the urine refers to the degree of dilution of the urine rather than the amount.

The nurse is teaching an adult client who is participating in rehabilitation for bladder retraining. Which amounts of urine would cause the bladder to distend above the symphisis pubis? 1. 100 ml. 2. 200 ml. 3. 500 ml. 4. 700 ml.

Correct Answer: 4 When amounts larger than 500 ml are present in the adult bladder, it becomes distended and rises above the symphysis pubis. 700 ml is the only amount listed that is above 500 ml.

The nurse is palpating the left flank area and feels a sharp edge with definite delineated margins. Based on this data, which is the nurse palpating? 1. An enlarged spleen. 2. An enlarged kidney. 3. The colon. 4. A distended bladder.

Correct Answer: 1 An enlarged kidney feels smooth and rounded, whereas an enlarged spleen feels sharper with a more delineated edge. Both organs lie in the left upper quadrant of the abdomen. Usually the kidneys are not palpable, but may be if enlarged. The colon should not be palpable, and the bladder is in the area over the symphysis pubis.

A client has a spinal cord injury with paralysis at C5 level. When completing discharge teaching, which client statement would require further teaching? 1. "I need to perform self-catheterization three times daily." 2. "I know I cannot look to see if my bladder is full." 3. "I need to avoid bladder distention." 4. "I'll drink adequate amounts of liquids."

Correct Answer: 1 Dysreflexia occurs in clients with spinal cord injuries at level T7 or higher. Bladder distention causes a sympathetic response that can trigger a potentially life-threatening hypertensive crisis. It would be crucial for the client with this type of injury to avoid bladder distention by performing self-catheterization before this happens, most likely every 3 to 4 hrs. By the time the client can see his abdomen expand or have a sense of bladder fullness—if able to have this sensation—it may be too late to avoid dysreflexia. Liquids are important in maintaining the urinary system.

The nurse is interviewing the parents of a toddler who state they are concerned about the child's bedwetting. Which response by the nurse is the most appropriate? 1. ""Be sure to limit the child's fluid intake during the evening." 2. "Don't worry; all children wet the bed." 3. "We'll obtain a specimen to check for a urinary tract infection." 4. "This problem will be gone at the age of 4."

Correct Answer: 1 Most bedwetting ceases by the age of 4 or 5. If the parents are concerned enough to bring the problem to your attention, they're interested in suggestions for help. Limiting fluid intake before bedtime or waking the child to void are methods to address the problem. Dismissing their concerns is not therapeutic. Ruling out a urinary tract infection may be appropriate but would have to be correlated with other symptomatology and assessment findings.

Since returning from surgery the client has not voided for 8 hours; therefore, the nurse determines it is necessary to assess the client for bladder distention. Which client position is appropriate for this assessment? 1. Supine with only a small pillow under their head. 2. Prone position. 3. Sitting in bed at a 45-degree angle. 4. Lying in a left lateral position.

Correct Answer: 1 The bladder, when empty, is usually not palpable. As the bladder fills, the fundus can be palpated anywhere between the symphysis pubis to the level of the umbilicus When distended, the bladder will feel firm, smooth, symmetric, and non-tender. Lying supine with a small pillow under the head will allow for proper palpation of a distended bladder. The other positions will not allow proper palpation of the bladder.

The nurse is caring for an infant with newly diagnosed renal disease. Diagnostic tests for which system is the priority for this infant? 1. Ears. 2. Heart. 3. Lungs. 4. Joints.

Correct Answer: 1 The ears and kidneys develop at the same time in utero. Congenital deafness is associated with renal disease. Even though all other systems would be assessed to make sure their function is normal, the auditory function of the baby with known renal disease would be important to assess because of the embryonic development.

A client is admitted with possible renal calculi. The client asks, "Are there are any tests that can be performed to show the doctor if there are any kidney stones?" Which response by the nurse is the most appropriate? 1. "The intravenous pyelogram will allow the healthcare provider to visualize kidney stones." 2. "A 24-hour urine specimen will allow the healthcare provider to visualize kidney stones." 3. "A routine urinalysis will allow the healthcare provider to visualize kidney stones." 4. "A kidney biopsy will allow the healthcare provider to visualize kidney stones."

Correct Answer: 1 The intravenous pyelogram is a radiologic examination that allows visualization of renal calculi in the kidneys, ureters, and bladder. The other exams listed would not aid in visualization of renal calculi.

The nurse is assessing a client after a motor vehicle accident and notes the presence of ecchymosis in the left flank area. Which interpretation of this data is the most accurate? 1. Positive Grey Turner sign. 2. Costovertebral angle tenderness. 3. Possible clotting dysfunction. 4. A precursor to hematuria.

Correct Answer: 1 The presence of ecchymosis in the flank area is a positive Grey Turner sign and must be correlated to signs of trauma such as blunt penetrating wounds or lacerations. Tenderness in the costovertebral angle is a symptom the client would voice if present; ecchymosis in this area does not necessarily indicate tenderness. A clotting problem could cause bruising, but bruising in this specific area would be more indicative of a positive Grey Turner sign. Hematuria is not necessarily going to occur as a result of the findings.

The nurse is preparing a client for assessment of the urinary system. Which technique will the nurse include in this physical assessment? Select all that apply. 1. Inspection. 2. Palpation. 3. Percussion. 4. Auscultation. 5. Client interview.

Correct Answer: 1, 2, 3, 4 The nurse uses each of the listed techniques in the physical assessment of the urinary system. Inspection would be used for assessing factors such as the appearance of the urine; palpation would include assessing factors such as bladder distention; percussion is used to determine factors such as the presence of urine in the bladder; auscultation would be used in assessment of the renal arteries; and the client interview provides important information regarding the overall urinary history of the client. However, the client interview is a part of the health history not the physical assessment.

A client presents with a medical diagnosis of uremia. Which clinical manifestations does the nurse anticipate upon assessment? Select all that apply. 1. Itching. 2. Weight loss. 3. Altered mental status. 4. Fluid retention. 5. Insomnia.

Correct Answer: 1, 2, 3, 4 Uremia is a classic sign of renal failure in which urea and other nitrogen-containing waste products are found in the blood. Common symptoms include itching, weight loss, altered mental status, and fluid retention. Fatigue rather than insomnia is another symptom.

The nurse is interviewing a client regarding urinary health. Which response would the nurse include during the collection of subjective data? Select all that apply. 1. "Do you have difficulty starting your stream of urine?" 2. "After you urinate, does your bladder feel full or empty?" 3. "Do you ever have an accident or wet yourself when you sneeze?" 4. "Do you have to hurry to the bathroom when you have to urinate?" 5. "Your recent urinalysis reveals protein in the urine."

Correct Answer: 1, 2, 3, 4 Urinary retention or holding residual urine in the bladder after voiding creates the sensation that the client is unable to empty the bladder and may contribute to the development of infection. Difficulty starting a stream usually indicates prostate disease in the male client. Stress incontinence and urgency occur when there is loss of muscle control over urination. Telling the client the results of the recent urinalysis is an example of objective data.

The nurse is assessing a client admitted for oliguria of unknown origin. During the admission, the client asks the nurse what affects urinary output. Which responses are appropriate by the nurse? Select all that apply. 1. Bladder size. 2. Bowel patterns. 3. Medications. 4. Client temperature. 5. Fluid intake.

Correct Answer: 1, 3, 4, 5 Factors that influence the number of times and the amount of urine that a client voids include the size of the bladder, medications, the client's temperature, and fluid intake. Bowel pattern does not usually affect the amount of urinary output.

A client's blood pressure suddenly falls from 120/80 mmHg to 90/60 mmHg. Which major role of the kidney is causing this clinical manifestation? 1. Increasing hydrostatic pressure. 2. Release of renin. 3. Increasing glomerular filtration rate. 4. Dilation of renal vessels.

Correct Answer: 2 A drop in systemic blood pressure often triggers the juxtaglomerular cells to release renin. Renin acts on angiotensinogen to release angiotensin I, which is in turn converted to angiotensin II. Angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. Thus, the renin-angiotensin mechanism is a factor in renal autoregulation, even though its main purpose is the control of systemic blood pressure.

The nurse is admitting a client with constant, severe flank pain, spasms, nausea and vomiting, and oliguria. The client states that the pain was initially intermittent and radiated from the low back to the lower quadrants of the abdomen. Which nursing action is the priority for this client? 1. Administer pain medication. 2. Notify the healthcare provider immediately. 3. Obtain a urine specimen for culture. 4. Complete the assessment.

Correct Answer: 2 Hydroureter is a complication that occurs when a renal calculus moves into the ureter and blocks and dilates the ureter. Symptoms include severe pain and spasms, nausea and vomiting, and diminished volume of urine (oliguria). Hydroureter is a medical emergency that can lead to shock, infection, and subsequent impaired renal function, and medical collaboration should be initiated immediately. All other options would not be appropriate in an emergency situation.

The nurse is percussing over the client's symphysis pubis area and notes a dull tone. Which conclusion by the nurse is the most appropriate based on the data? 1. He or she is assessing the right kidney. 2. A full bladder. 3. A bladder tumor. 4. Air trapped in the intestines.

Correct Answer: 2 Percussion over a full bladder produces a dull tone. An empty bladder sits low in the pelvic cavity behind the symphysis pubis, and would be difficult to percuss. Percussion over one of the kidneys would also produce a dull tone, but these organs lie lateral and superior to the bladder. Air trapped in the intestines would produce tympany.

An older adult female comes into the clinic to be seen for urinary incontinence. Which conclusion by the nurse is the most appropriate? 1. Is common with aging. 2. Often occurs as a secondary problem. 3. Indicates decreased renal blood flow. 4. Is related to medications.

Correct Answer: 2 Urinary incontinence is not a normal sign of aging and therefore should be evaluated further for this client.

The nurse is preparing an educational session on kidney health for a church group. Which group would the nurse note to have the highest incidence of end-stage renal disease? 1. Mexicans. 2. Asians. 3. African Americans. 4. American Indians.

Correct Answer: 3 Although all the listed populations have higher rates of renal disease than Caucasians, the occurrence of end-stage renal disease is highest in the African American group.

The nurse is interviewing an older adult client in the clinic who reports incontinence. Numerous attempts in the recent past have been unsuccessful in helping to control the problem. Which is the priority diagnosis for this client? 1. Skin integrity impairment. 2. Self-care deficit. 3. Self-esteem, situational-low. 4. Infection.

Correct Answer: 3 Clients suffering from incontinence are at increased risk for social isolation, self-esteem disturbance, and other psychosocial problems. There is no data to support a self-care deficit; the information available is that this client has tried to implement measures to treat the problem. The client is certainly at risk for infection and skin integrity impairment, but these two are not active at this time.

The nurse is interviewing a client who states the presence of urinary incontinence with coughing and sneezing. Which term will the nurse use when documenting this finding in the medical record? 1. Functional. 2. Reflex. 3. Stress. 4. Urge.

Correct Answer: 3 Stress incontinence is involuntary urination occurring with coughing, sneezing, or straining. Stress incontinence can be either partial or complete leakage of urine from the bladder. Functional incontinence results when there is an inability to reach the toilet in time; reflex incontinence occurs with spinal cord damage; and urge incontinence may be due to excessive intake of fluids, diminished bladder capacity, or urinary tract infection.

During the assessment of a client's renal system, the nurse is unable to palpate the kidneys. Which conclusion by the nurse is the most appropriate? 1. An indication of an inflammatory condition of the kidneys. 2. A sign of acute or chronic renal disease. 3. Normal. 4. A sign of polycystic kidney disease.

Correct Answer: 3 The kidneys are normally not palpable; therefore, the other options are not indicated by being unable to palpate the kidneys.

An adolescent visits the school nurse to ask why she is getting frequent urinary tract infections. Which questions should the nurse ask the client during this visit? Select all that apply. 1. "Have you been eating foods that have high acidity?" 2. "Do you drink a lot of milk?" 3. "Do you take bubble baths frequently?" 4. "What direction do you wipe after a bowel movement?" 5. "Do you have a family history of urinary tract infections?"

Correct Answer: 3, 4 Females should wipe the peri-anal/genital area from front to back. E-coli is the most common microorganism responsible for urinary tract infections and can easily be dragged into the urethral orifice by wiping from the anus to the urethra after defecation. Females do have a shorter urethra compared to males and are more susceptible to urinary tract infections for this reason. Taking frequent bubble baths has also been found to lead to urinary tract infections in females. Eating foods high in acidity, drinking large amounts of milk, and family members with urinary tract infections does not increase the risk for urinary tract infections.

The nurse is collecting a urine specimen from a client and notes the urine is foamy and amber in color. Based on this data, which diagnosis would the nurse suspect? 1. Kidney stones. 2. Urinary tract infection. 3. Prostate disease. 4. Liver disease.

Correct Answer: 4 Foamy, amber-colored urine may indicate the presence of hepatic illness (liver disease). Pain is the primary symptom for the client with kidney stones. The pain may radiate and is variable in location and severity. Other symptoms include spasms, nausea, vomiting, pain on urination, frequency and urgency of urination, and gross hematuria. If a urinary tract infection is present, the client may complain of pain during urination with urgency, frequency, dribbling, pain upon urination, and suprapubic or lower back pain. Hematuria, as well as cloudy and foul-smelling urine may also accompany a urinary tract infection. Prostate disease may make it difficult for male clients to begin or maintain their urine stream.

The nurse is caring for a client admitted with an infection of the ureters. The nurse realizes this infection could include which structure of the kidney? 1. Capsule. 2. Cortex. 3. Medulla. 4. Pelvis.

Correct Answer: 4 Since the renal pelvis is continuous with the ureter at the end of the ureter; therefore, an infection in the ureters could travel to the renal pelvis. The renal capsule, cortex, and medulla are not continuous with the ureters.

The nurse is able to percuss a dull tone over a client's bladder after the client has voided 300 ml of urine. Which conclusion by the nurse is the most appropriate? 1. This is a normal finding. 2. Possible urinary tract infection. 3. This is a sign of prostate enlargement. 4. Probable urinary retention.

Correct Answer: 4 This is not a normal finding as there should be little to no urine remaining in the bladder following urination. A dull percussion tone over the bladder of a client who has just urinated indicates urinary retention, and further evaluation is necessary. Urinary retention can lead to urinary tract infections, but this could not be concluded without additional testing. Prostate enlargement usually affects the client's ability to start the urine flow and maintain a strong urine flow, so urinary retention would not indicate this condition.

The nurse is performing a urinary system assessment and wishes to percuss at the right costovertebral angle. When assessing this location on the client, which area of the kidney is assessed?

Correct Answer: C The nurse places the right hand flat over the right costovertebral angle, then thumps the back of the right hand with the ulnar surface of the left fist. Pain or discomfort during and after blunt percussion suggests kidney disease. The client should feel no pain or tenderness with pressure or percussion, but findings must be correlated with other assessment data.

Which structure in the kidney is made up of pyramids and calyces, whose function is to collect urine and transport it into the renal pelvis?

Correct Answer: C The renal medulla is composed of structures called pyramids and calyces. The pyramids are wedge like structures made up of bundles of urine-collecting tubules. At their apex, the pyramids have papillae that are enclosed by cuplike structures called calyces. The calyces collect urine and transport it into the renal pelvis, which is the funnel-shaped superior end of the ureter.